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Pre-mesencephalic subarachnoid hemorrhage: rupture of tiny aneurysms of the basilar artery perforator

  • Neurovascular Observations
  • Published:
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Abstract

Purpose

Subarachnoid hemorrhage (SAH) around the midbrain without evidence of aneurysm, a so-called perimesencephalic SAH, has been considered a typical nonaneurysmal SAH. Recently, we have encountered several patients with SAHs that could have been classified as having perimesencephalic SAH, but a common cause of the bleeding was demonstrated. In this article, we describe clinical and radiologic characteristics of these patients.

Methods

Clinical and radiologic data from patients with spontaneous SAH (total number 339) who were treated at Seoul National University Bundang Hospital between May 2003 and December 2007 were reviewed.

Results

Of the 13 patients that could be classified as having perimesencephalic SAH, three had common radiologic features that were distinct from others. On computed tomography, the main hemorrhage (hematoma) was found localized in front of the midbrain (interpeduncular and/or peduncular cistern). Angiographically, the cause of the bleeding was not seen on conventional views and rotational angiograms. In three-dimensional reconstructed angiographic images, very small-sized (tiny) aneurysmal lesions were visible at the origin of mesencephalic perforators from the basilar artery. All the aneurysms were positioned at the exact site corresponding to the pre-mesencephalic clots. Follow-up angiography was performed on the three patients and all showed complete disappearance of the lesions at 1 month, 15 months, and 16 months follow-up, respectively.

Conclusions

Based on our experience, we suggest a subtype of spontaneous SAH that has unique hemorrhage localization (pre-mesencephalic cistern), specific cause (tiny aneurysms at the origin of the mesencephalic perforator), and a common benign clinical course.

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References

  1. Hashimoto H, Iida J, Shin Y, Hironaka Y, Sakaki T (2000) Spinal dural arteriovenous fistula with perimesencephalic subarachnoid haemorrhage. J Clin Neurosci 7:64–66. doi:10.1054/jocn.1998.0145

    Article  CAS  PubMed  Google Scholar 

  2. Ociichi T, Endo S, Onizuka K, Takaba M, Takaku A, Yasuda M (1997) Non-aneurysmal subarachnoid hemorrhage associated with basilar artery dissection: autopsy case report. Neurol Med Chir (Tokyo) 37:612–615. doi:10.2176/nmc.37.612

    Article  Google Scholar 

  3. Rinkel GJE, van Gijn J, Wijdicks EFM (1993) Subarachnoid hemorrhage without detectable aneurysm: a review of the causes. Stroke 24:1403–1409

    CAS  PubMed  Google Scholar 

  4. Schaaf ICVD, Velthuis BK, Gow A, Rinkel GJE (2004) Venous drainage in perimesencephalic hemorrhage. Stroke 35:1614–1618. doi:10.1161/01.STR.0000131657.08655.ce

    Article  PubMed  Google Scholar 

  5. Schievink WI, Wijdicks EFM (2000) Origin of pretruncal nonaneurysmal subarachnoid hemorrhage: ruptured vein, perforating artery, or intramural hematoma? Mayo Clin Proc 75:1169–1173. doi:10.4065/75.11.1169

    Article  CAS  PubMed  Google Scholar 

  6. Spallone A, Ferrante L, Palatinsky E, Santoro A, Acqui M (1896) Subarachnoid haemorrhage of unknown origin. Acta Neurochir (Wien) 80:12–17. doi:10.1007/BF01809551

    Article  Google Scholar 

  7. van Gijn J, van Dongen KJ, Vermeulen M, Hidra A (1985) Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology 35:493–497

    PubMed  Google Scholar 

  8. Watannabe A, Hirano K, Kamada M, Imamura K, Ishii N, Sekihara Y, Suzuki Y, Ishii R (2002) Perimesencephalic nonaneurysmal subarachnoid haemorrhage and variants in the veins. Neuroradiology 44:319–325. doi:10.1007/s00234-001-0741-3

    Article  Google Scholar 

  9. Wijdicks EFM, Schievink WI (1997) Perimesencephalic nonaneurysmal subarachnoid hemorrhage: first hint of a cause? Neurology 49:634–636

    CAS  PubMed  Google Scholar 

  10. Wijdicks EFM, Schievink WI, Miller GM (1998) Pretruncal nonaneurysmal subarachnoid hemorrhage. Mayo Clin Proc 73:745–752. doi:10.4065/73.8.745

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Korea Cancer Center Hospital, Seoul, Korea

    Sukh Que Park

  2. Department of Neurosurgery, School of Medicine, Seoul National University, Neuroscience Center, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Seoul, Korea

    O-Ki Kwon & Chang Wan Oh

  3. Department of Radiology, Seoul National University School of Medicine, Seoul, Korea

    Seong Hyun Kim & Moon Hee Han

  4. Neuroscience Center, Seoul National University Bundang Hospital, Seoul, Korea

    O-Ki Kwon & Chang Wan Oh

  5. Department of Radiology, Seoul National University Hospital, Seoul, Korea

    Moon Hee Han

Authors
  1. Sukh Que Park
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  2. O-Ki Kwon
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  3. Seong Hyun Kim
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  4. Chang Wan Oh
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  5. Moon Hee Han
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Correspondence to O-Ki Kwon.

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Comment

The authors, from Seoul National University, have found three cases out of a total of 13 patients with perimesencephalic subarachnoid hemorrhage (SAH) who were found to have a tiny (1 mm or less) aneurysm at the top of the basilar artery in relation with the origin of one of the mesencephalic perforators. All three of these patients, while qualifying for the definition of “perimesencephalic SAH” had the peculiarity that the maximal density of blood was in the interpeduncular “pre-mesencephalic” cistern. All three patients were treated conservatively for very good reasons, since it would have been not only difficult but also probably very dangerous to attempt to treat these aneurysms with either direct surgery (clipping) or any kind of endovascular procedure. None of the patients re-bled and in all three, the tiny aneurysm eventually disappeared as they were carefully followed with serial angiography. In other words, they ran a clinical course consistent with that of other patients with “perimesencephalic SAH”. This suggests that perhaps many patients with perimesencephalic SAH, particularly when the clot is localized in the pre-mesencephalic region, may indeed have a tiny aneurysm as the cause of their hemorrhage. It is important to note that in none of these three patients was the aneurysm detected in conventional angiographic views and only the 3D reconstructions showed the abnormality. There has been a tendency to treat these patients with “peri-mesencephalic SAH” and a negative initial angiogram rather casually even sending them home and allowing them to undertake regular activities within a few days of their SAH, since the general feeling is that these hemorrhages are non-aneurysmal and “benign”. This article reinforces my belief that these patients should be treated with the same precautions that we take for other patients with aneurysmal SAH (bedrest for at least a week, careful control of the blood pressure, etc.). In addition, I will make sure to look much more carefully at the reconstructed 3D images of the top of the basilar artery to see if one of these tiny aneurysms is detected. Since treatment of these aneurysms would be very dangerous or impossible, it is reassuring that at least the three patients reported by the authors did well and the aneurysm healed spontaneously.

RC Heros

Miami, Florida

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Park, S.Q., Kwon, OK., Kim, S.H. et al. Pre-mesencephalic subarachnoid hemorrhage: rupture of tiny aneurysms of the basilar artery perforator. Acta Neurochir 151, 1639–1646 (2009). https://doi.org/10.1007/s00701-009-0416-0

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  • DOI: https://doi.org/10.1007/s00701-009-0416-0

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